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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Competing Priorities
Authors Respond to Comments on Screening Children for Family Violence: Clarifying the Scope of the Systematic Review
Evidenced Based Screening for Child Abuse and Family Violence: Experienced Based Caution
Screening Children for Violence
Looking Forward in Dealing With Child Abuse
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Brian K. Crownover, Offutt AFB, NE Training Instructor, Offutt AFB/University of Nebraska Medical Center Family Medicine Residency
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I appreciate the insightful comments on this Track string from the other physicians providing feedback; however, I noted a theme that evidence -based medicine (EBM) did not apply well to this topic. Although many points to support this stance were valid, I am still left pondering how to spend my precious few moments each day on prevention and screening. I need the most "bang for the buck" when weighing how to solve the dilemma described by Yarnall et al; "to fully satisfy the USPSTF recommendations, 1773 hours of a physician's annual time, or 7.4 hours per working day, is needed for the provision of preventive services." Since I MUST selectively use some screens while defering others, an EBM article which quantifies a tool's value, such as the one from Nygren et al is highly desired. Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003 Apr;93(4):635-41. Competing interests: None declared |
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Peggy M Nygren, Portland, USA Research Associate, OHSU, Heidi D. Nelson, MD, MPH
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Response from authors: We agree with many of the thoughtful comments of Drs. Sirotnak, Flaherty, and Alexander. The issue of child abuse and neglect in the U.S. is one of great importance and deserves much attention. The number of child abuse and neglect cases in the U.S. is alarming. Associations between early adverse childhood experiences and later impact on physical and mental suffering should raise concern among all clinicians, not only those caring for children. Also noted, is that some forms of abuse cannot always be predicted in the primary care setting, such as one time caretaker rage events. Under contract to the Agency for Health Care Research and Quality (AHRQ), this evidence-based review was developed to inform the U.S. Preventive Services Task Force (USPSTF). With guidance from this group, the authors set out to describe the evidence on a very focused set of questions. While acknowledging the complexity of the child abuse and neglect issues the readers raise, this systematic evidence review does not cover all ground. Its main objective was to determine the effectiveness of routine screening of children without signs, symptoms, or conditions associated with abuse or neglect. Children suspected of suffering abuse or neglect are not screened, they are evaluated. This situation, and the related research, were outside the scope of this review. As is the case with many important health topics, the review was limited by the available literature on this subject. No studies evaluated the effectiveness of screening in reducing abuse or improving health outcomes. A number of studies stratified patients into risk categories and assigned them to a variety of intervention groups. It is not clear how well these studies translate to routine screening in healthcare settings. Screening for child abuse is certainly different than screening for cancer, but it may be analogous to screening for depression or alcohol use. The effectiveness of these screening approaches has been demonstrated and the U.S. Preventive Services Task Force practice guidelines have changed as a result. This evidence-based review describes the status of the existing evidence on screening and intervention approaches for child abuse and neglect, as well as highlights the existing gaps in research. Ultimately this work will also inform both researchers and funders. Finally, filling these gaps may provide additional guidance to clinicians who care for children subjected to abuse or neglect. Peggy Nygren, MA Heidi D. Nelson, MD, MPH Competing interests: None declared |
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Andrew Sirotnak,MD, Denver,CO Assc.Professor Pediatrics, University of Colorado School of Medicine, The Children's Hospital
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The article by Nygren, Nelson, and Klein in the Annals of Family Medicine March/April issue entitled Screening Children for Family Violence: A Review of the Evidence for the US Preventive Services Task Force closely parallels the articles by the same authors which addressed screening women and elderly patients and intimate partner violence. The authors should be commended for attempting to place clarity to the US Preventive Services Task Force recommendations on screening for family and intimate partner violence for a very cogent analysis of the medical literature to date. Both articles highlight difficulties in screening the medical literature for abstracts and articles which meet the very analytic framework and key questions for the authors’ review of these studies. I heartily agree with the editorial by Mark S. Lachs, MD, MPH from Weill Medical College at Cornell University in the same issue. The limitations that evidence-based medicine and its applications to the screening for forms of violence and abuse are significant but in no way should be interpreted as a reason not to screen for violence and abuse in our primary care populations. On the contrary, relying on evidence-based goals and screening criteria will only lead to both missed cases, a false sense of security in a negative screen, and a dangerously misplaced rationale that the screening is not worth doing at all. The latest statistics from the US Department of Health and Human Services, Child Maltreatment 2002, do not show any significant decrease in either the total number of cases reported or the founded number of child abuse cases. The number of fatal child abuse cases in the United States continues to climb. Looked at in a broader context, in 2001 about 7000 children in the United States were diagnosed with all forms of childhood cancer and leukemia, whereas, during the same year, over 900,000 children were victims of abuse or neglect. There certainly is no other pediatric health care condition, disease or syndrome that has more far-reaching implications for overall physical and emotional development than child abuse and neglect. Additionally, more mental health care dollars are spent on the treatment and sequelae of abuse than any other isolated mental health diagnosis or condition. The authors very effectively point out that there are few studies which can meet their rigorous evidence-based criteria for identification and screening of child abuse and neglect. Holding such screening studies or tools to the same standard as, for example, colonoscopy for evaluation of malignant polyps or mammograms for breast cancer is certainly misleading. I would suggest the readers consider the tremendous difference in a malignant or family-inherited disease when comparing that to child abuse. Diagnosis of such disease or syndrome would be quite linear and uncomplicated, that is, the family history of colon cancer or hypertension and a positive review of systems in an individual such as rectal bleeding or elevated blood pressure with stroke. The etiology and epidemiology of family violence, inter-personal violence and child abuse is multi-factorial, can be multi-generational and hard to predict or prevent. Moreover, many episodes of child abuse and neglect are the result of impulsive, rageful, or uncontrollable and, very often, unpredictable acts of violence. For example, the most common form of abuse in children under the age of two years, with significant morbidity and mortality, abusive head trauma, is often a one-time, unpredictable event where crying or irritability triggers a loss of control in a caregiver. That caregiver shakes or throws the infant in frustration. No screening study administered to a parent or caregiver could ever predict that such an event would occur. In their paper, the authors mention the work of David Olds, Ph.D. which shows a remarkable period of intensive, rigorous study that prenatal and infancy home visitation services have many positive effects on the health of families and children including a decrease in incidence of abuse and neglect. I would also direct the readers to a word of caution regarding what the authors describe as harms of screening and interventions. Although it is true that false positive tests could lead to, what the authors describe as “inappropriate labeling and punitive attitudes”, a false negative screening test is far more dangerous. The authors state that this “may hinder the identification of those who are truly at risk,” but more importantly, relying on a screening test to identify abuse or neglect may actually leave a family or child at significant risk and a dangerous situation or abusive injury may be missed. This delicate balance of risk benefit in both discussing abuse and neglect concerns with families and the reporting of abuse and neglect, which is mandated by law in every state, is certainly something that we, as primary care providers, struggle with daily. Education of pediatric and family medicine and other primary care physicians during residencies, as well as education of all physician- extenders, must do a better job at the education, identification and reporting of child abuse and neglect. I do feel, however, that the authors are somewhat misguided in their discussion as they mention the detection of child abuse and neglect by clinicians “could potentially reduce serious harms to children.” The detection of abuse and neglect CAN reduce serious harms to children. Screening for abuse or risk of abuse presents unique challenges but the actual detection of abuse and neglect, and its subsequent mandated reporting can, and will, reduce serious harms to children. Mandatory reporting does not always require the identification of confirmed abuse. The reporting laws in all 50 states are similar but the requirements for reporting may vary from “reasonable suspicion” that abuse and neglect has occurred to actual medical indication that abuse has occurred. For example, a clear disclosure of sexual abuse by a young child is mandated to be reported as suspected sexual abuse, and that child need not have an abnormal physical examination of presence of a sexual transmitted disease to confirm sexual abuse. There are a multitude of child abuse articles, textbooks, atlases and peer-review literature that have clearly and consistently outlined the spectrum of injuries that should raise concern of sexual abuse, physical abuse, or neglect. The authors also state that the feasibility of the screening and interventions in health-care settings must consider the cost, time and resources, clinician consistency, barriers and patient compliance. Certainly, all of these factors complicate the ability of a physician to screen for violence and abuse in their families. It must be emphasized, however, that once again, the balance of not screening for these issues greatly outweighs the morbidity and mortality of the effects of abuse, neglect, and violence on children and their families. Physicians routinely rate the identification of maltreatment as difficult to do, and cite work pressure and awkwardness in this situation as primary barriers. It can be argued that with the use of screening and assessment tools in the office setting, even on a sporadic basis with high-risk populations, the clinicians can become more comfortable and comfortable with issues of abuse, neglect, and violence The last paragraph of this very important paper is somewhat misleading to primary care physicians who are actively seeking self- education and guidance on the important issues of screening for abuse and violence in their families. Indeed, there may be few studies providing “evidence-based data” for the accurate detection of child abuse and violence in children and their families. The authors made a rather inappropriately broad statement that clinicians “have difficulty” fulfilling their role in prevention and treatment of the harms of family violence. I would suggest that clinicians may indeed have difficulty fulfilling this role in the context of a busy primary care practice. But there is wealth of medical literature, both peer-review, case review and continuing medical education publications that can effectively guide the physician on how to deal with this issue. There are volumes of medical information that can guide primary care physicians in the identification, assessment of risk, and management and treatment of abuse and neglect. Several of these guidelines are actually referred to in this article. This myriad of resources that can be accessed to self-educate and to guide the practices of clinicians regarding child abuse and neglect and family violence of course needs to be balanced with the comfort level that develops with clinical experience and consultation with other colleagues. The American Academy of Pediatrics has a section on child abuse and neglect with members in every state and region of the United States. These expert clinicians have dedicated their clinical, academic and research careers to field of child abuse and neglect can be contacted for guidance on this very complex issue. Competing interests: None declared |
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Emalee G. Flaherty, Chicago, IL Pediatrics, Children's Memorial Hospital and Northwestern Feinberg School of Medicine
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The authors have systematically reviewed the studies published about screening children for abuse and neglect. The article is well referenced. They note that all the screening tools they found were directed to parents. They suggest that tools should be developed to screen older children during health care visits. The American Academy of Pediatrics’ Guidelines for Health Supervision III outlines questions and contains screening forms to be used to screen for family violence and abuse when evaluating older children. Some of the authors’ conclusions are not well substantiated. The authors state that their aim was to evaluate the benefits and harms of screening, but mix screening to determine which children may be at risk for abuse with screening for children who have suffered abuse. These are two separate types of screening. The screening instruments they cite identify factors that make a child vulnerable for abuse. They did not evaluate screening children for abuse. I was confused by their statement that “few clinicians screen patients who do not have apparent injury”. Generally, an injury should be the trigger that causes the clinician to consider the possibility of physical abuse. Otherwise, a clinician is screening for risk as demonstrate by their references following this statement. These references discuss office screening for domestic violence. Screening tests have limitations and will never identify all children who are vulnerable to abuse. Although many risk factors have been identified, many families have no identifiable risks. A parent’s unwillingness to share personal information may limit the effectiveness of screening. Perhaps, just being a child places a child at risk for abuse. Another limitation is that screening tools are directed towards parents. Although parents are the most common perpetrator of abuse and neglect, other caretakers including other family members and babysitters are also frequently implicated and would not be identified through screening. Screening by itself does not reduce risk. Risk reduction depends on providing effective prevention and intervention. The authors evaluate the performance of the screening instruments by studying the effectiveness of interventions. The success of an intervention depends on the quality of the intervention. Because screening tests do not identify all children who are vulnerable, I agree with Dr. Alexander that prevention programs should target all families with the goal of helping parents to be good parents. These programs should also advise them about how to choose other caretakers wisely. Guidelines for Health Supervision III ,Elk Grove Village, IL American Academy of Pediatrics; 1997. Competing interests: None declared |
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Randell C Alexander, Atlanta, USA Professor of Pediatrics, Morehouse School of Medicine
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The authors correctly identify that much research needs to be done on screening for child abuse. Screens looking at risk often predict essentially whether someone has a Medicaid card or not. Screens to pick up current child abuse are only fair and maybe too user dependent. Some of their data is essentially wrong (e.g. no child abuse expert believes that there are 1100 child abuse deaths per year - the number is about 2000 or more) and some ignores considerable knowledge in the field not accessible by search engines. Indeed one of the hazards of relying exclusively on published data is that it is "old" and shows where we have been, not where we are. All of this may miss the point. There is a considerable body of research that shows that targeted intervention for prevention (targeted to those screened) does not work as well as univeral approaches. There are estimates from Prevent Child Abuse America that child abuse costs us $94 billion per year; and a number of studies by Fellitti and Anda showing that adverse childhood experiences have major impact over many adult diseases (one colleague estimates that internists would lose 1/3 of their business if child abuse was eliminated). Thus a better screen may not be the most interesting question. Prevent Child Abuse America, the American Academy of Pediatrics, and others are involved in pioneering research further proving the value of home visitation and new concepts on putting prevention into the physician's office. The authors are right that it is imperative that at some point to have hard data to substantiate whether something works or not. Within the next decade we no doubt will see substantial documentation of what works, and probably that it works quite well. Then, literature searches will show the children who have already been helped. Competing interests: None declared |
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